Complaints Grievances

These are the Commonwealth of Pennsylvania’s definitions for both a complaint and a grievance as they pertain to Medicaid behavioral health services. Please choose the topic that best applies to your current needs. Once you select an option, you will find more information.

• A complaint is a dispute or objection filed with the Behavioral Health Managed Care Organization (BH-MCO) regarding a participating health care provider or the coverage, operations, or management policies of a BH-MCO.

• A grievance is a request to have a BH-MCO or utilization review entity reconsider a decision concerning the medical necessity and appropriateness of a health care service.

In accordance with federal and state changes to Medicaid managed care regulations, Community Care has made changes to its complaint and grievance processes. These changes will take effect on September 1, 2018. For more information, call us.